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Coroners’ concerns to prevent harms: a series of coroners’ case reports to serve patient safety and educate the public, clinicians and policy-makers
  1. Georgia C. Richards1,
  2. Jeffrey K. Aronson1,2,
  3. Carl Heneghan1
  1. 1 Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  2. 2 Centre for Evidence-Based Medicine, University of Oxford, Oxford, UK
  1. Correspondence to Georgia C Richards, Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 2JD, UK; georgia.richards{at}

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Understanding the causes of deaths and how they can be prevented is critical for improving healthcare outcomes. At a population level, over-reporting or under-reporting of deaths can have a profound impact on policy decisions, which in turn affect global economies and the day-to-day lives of citizens. At the individual level, understanding how and why deaths occur may prevent similar deaths or serious harms from occurring in the future. One in 20 people are exposed to preventable harms in medical settings globally, and 12% of preventable harms result in disability or death.1

Coroners’ reports hold a wealth of information on the circumstances of individual deaths. In England and Wales, the law requires coroners to report and communicate a death when the coroner believes that action should be taken to prevent deaths.2 These reports, named Prevent Future Deaths (PFDs), are mandated under paragraph 7 of schedule 5 of the Coroners and Justice Act 2009, and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.3 4 Under these regulations, individuals or organisations that receive a PFD report are required under statue to respond to the coroner within 56 days of receiving the report, to outline actions proposed or taken to address the coroner’s concerns. The Courts and Tribunals Judiciary website hosts the PFD reports and responses to the reports.5

As these reports contain valuable lessons, concerns have been raised regarding the lack of dissemination and communication of these lessons.6 Alerting national rather than local organisations about the lessons from these deaths has been one recommendation for serving patient safety initiatives in the National Health Service (NHS).7 However, the lessons from these deaths are far-reaching, and not just applicable to the NHS. Thus, we launch this new series in order to identify relevant case reports that have important lessons for the public and professional communities, and the potential to prevent similar deaths. Although coroners’ reports are concerned with deaths, they contain lessons that may help in preventing non-fatal harms as well, and so we include those in our purview, and title our series, ‘Coroners’ Concerns to Prevent Harms’.

Evidence-based medicine and coroners’ concerns

Evidence-based medicine incorporates clinical expertise, patient values and the best external evidence.8 Although systematic reviews and randomised controlled trials are the strongest forms of evidence, case reports increasingly have an important role in identifying harms in medicine.9 10

Each month we aim to publish a PFD case report that is relevant to evidence-based medicine and the wider community, and provides valuable lessons to prevent fatal and serious non-fatal harms. Our articles will include information on the coroner’s report, what concerns were raised by the coroner, what the evidence says, and the implications or recommendations to prevent harms and potential deaths. We shall document responses and actions taken by individuals and organisations that received the coroner’s report, and highlight when a response to the report is unrecorded and overdue. The idea for the Coroners’ Concerns to Prevent Harms series was stimulated by a rapid response letter in The BMJ11 and after a fruitful debate at the 4E’s Forum to Improve the Detection, Analysis and Reporting of Harms in Medicines12 .

This month we publish the first in this series, on the toxicity and lethality of alcohol-based hand sanitisers, a pertinent issue, as our exposure to and demand for these products increase13 (). While acknowledging the importance of improving hand hygiene to prevent the transmission of diseases such as COVID-19, in this article we provide eight recommendations that require urgent action to safeguard vulnerable individuals, including children, elderly people and high-risk patients with substance abuse or histories of self-harm.

We have collated all coroners’ PFD cases uploaded to the Courts and Tribunals Judiciary website, using an open and reproducible method called ‘web scraping’, which automates the collection of all reports and responses to the reports, and creates a database of case information. We have recently described the power of web scraping for those eager to learn.14 This web scrape can be rerun to update the database as new coroners’ cases and responses to cases are uploaded. The web scrape is openly available at GitHub,15 and we have created a website to display the scraped data, which will be updated with results and content as we continue to analyse the data.16 We are continually screening coroners’ PFD reports to identify pertinent cases, with lessons to prevent harms. This process is iterative, and we welcome readers’ thoughts and feedback as we develop the BMJ EBM series on Coroners’ Concerns to Prevent Harms.


The idea for this series was stimulated by a rapid response letter from JK Aronson to the BMJ in October 2018, and the letter, alongside preliminary findings on deaths from opioids in the coroner’s PFD database, was presented by GC Richards at the 4E’s Forum to Improve the Detection, Analysis and Reporting of Harms in Medicines, in Erice, Sicily, October 2019.



  • Twitter @Richards_G_C, @JKAronson, @carlheneghan

  • Contributors All authors contributed to the idea for this editorial. GCR wrote the first draft. JA and CH revised and edited the manuscript. All authors read, reviewed and approved the final manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

  • Competing interests GCR is financially supported by the National Institute of Health Research (NIHR) School for Primary Care Research (SPCR), the Naji Foundation, and the Rotary Foundation to study for a Doctor of Philosophy (PhD) at the University of Oxford. GCR is the Editorial Registrar of BMJ Evidence Based Medicine. JA is an Associate Editor of BMJ Evidence Based Medicine; he has published articles and edited textbooks on adverse drug reactions and interactions and has often given medicolegal advice, including appearances as an expert witness in coroners’ courts. CH is Editor in Chief of BMJ Evidence-Based Medicine. CH is an NIHR Senior Investigator and has received expenses and fees for his media work (including payments from BBC Radio 4 Inside Health), received expenses from the WHO and FDA, and holds grant funding from the NIHR, the NIHR SPCR, the NIHR SPCR Evidence Synthesis Working Group (Project 380), the NIHR BRC Oxford and the WHO. CH has received financial remuneration from an asbestos case and given free legal advice on mesh cases. CH has also received income from the publication of a series of toolkit books published by Blackwells. On occasion, CH receives expenses for teaching EBM and is also paid for his GP work in NHS out of hours (contract with Oxford Health NHS Foundation Trust). CH is Director of CEBM, which jointly runs the EvidenceLive/EBMLive Conference with the BMJ and the Overdiagnosis Conference with international partners, based on a non-profit making model.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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